Provider Demographics
NPI:1063722700
Name:WHITE MARSH HEALTHCARE PHYSICAL MEDICINE LLC
Entity type:Organization
Organization Name:WHITE MARSH HEALTHCARE PHYSICAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-600-5807
Mailing Address - Street 1:5430 CAMPBELL BLVD.
Mailing Address - Street 2:STE. 106
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162
Mailing Address - Country:US
Mailing Address - Phone:443-725-4930
Mailing Address - Fax:443-725-4933
Practice Address - Street 1:5430 CAMPBELL BLVD.
Practice Address - Street 2:STE. 106
Practice Address - City:WHITE MARSH
Practice Address - State:MD
Practice Address - Zip Code:21162
Practice Address - Country:US
Practice Address - Phone:443-600-5807
Practice Address - Fax:443-725-4933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03606111N00000X
MD03470111N00000X
MDMD20215207R00000X
MDD27411208D00000X
208VP0014X, 332B00000X, 208100000X
MDC3824363A00000X
MDC0000614363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6503310001Medicare NSC
216142Medicare PIN